Academic medical center access and outcomes in Kaposi sarcoma.
Authors: Michelle Swedek, Peter T. Silberstein, Victoria Vardell
Journal: Journal of Clinical Oncology (2023)

e21582 Background: Kaposi sarcoma (KS) is a soft tissue tumor commonly affecting the skin. It is seen in patients in immunosuppressed states, such as those with HIV/AIDS or organ transplant history. Treatment may include excision, chemotherapy, or radiotherapy depending on the location and spread of lesions. Prior studies indicate that treatment at academic facilities, which offer higher treatment volume, and access to specialized care, clinical trials, and a greater number of ancillary services, is associated with improved survival in other skin cancers, such as melanoma. In this study we aim to compare the survival and sociodemographic factors for KS patients between academic and non-academic facilities, using the largest dataset of these patients yet examined. Methods: We conducted a retrospective analysis of the National Cancer Database from 2004 to 2019 for subjects with KS, identified by ICD code 9140 (n=5,233). Factors were compared between patients seen at non-academic (NAC) (n=2,278) versus academic centers (AC), (n=2,955). Overall survival (OS) was estimated using Kaplan Meier analysis with pairwise log-rank tests for significance. Multivariate analysis was performed using binary logistic regression. Results: Most individuals in the study were White (70.1%), male (87.1%), not of Spanish or Hispanic origin (82.7%), and had government insurance (54.3%). Treatment at AC was associated with improved survival compared to NAC (median OS 184 vs. 98 months, p&lt;0.001). AC patients were younger compared to NAC patients (mean age 56.1 vs. 60.9 years old, p&lt;0.001). On adjusted logistic regression, AC were more likely to treat minority patients, including Black patients (OR 1.23, 95% CI 1.06-1.43, p=0.005) and Spanish/Hispanic patients (OR 1.26, 95% CI 1.06-1.48, p=0.007). AC were more likely to manage uninsured patients compared to patients with private (OR 0.48, 95% CI 0.39-0.60, p&lt;0.001) or government insurance (OR 0.69, 95% CI 0.55-0.86, p=0.001). Compared to the East Coast, patients in the Central U.S. (OR 0.81, 95% CI 0.71-0.93, p=0.003) and West Coast (OR 0.83, 95% CI 0.71-0.96, p=0.015) were less likely to use AC. Patients residing in high education zip codes were less likely to be treated at academic centers (p&lt;0.001). Patients in the top income quartile were more likely to be treated at AC (OR 1.42, 95% CI 1.15-1.75, p=0.001). Conclusions: Treatment at AC is associated with improved overall survival compared to NAC in KS. AC were more likely to treat younger patients, and those from racial and ethnic minorities, as well as those in the top income quartile. Less academic center use was seen in areas of higher educational attainment and by individuals with government or private insurance. While specialized care and clinical trial access may play a role in this survival benefit, access to AC may also be a surrogate marker of social determinants of health that play a role in KS outcomes. Our study supports the ongoing need for access to comprehensive care in KS.